Transcript Adjusted Birth Weights

PREGNANCY SMOKING AND CHILD
OUTCOMES FROM BIRTH TO 15 MONTHS:
FINDINGS FROM NORTHEAST TENNESSEE
Beth Bailey, PhD
Associate Professor of Family Medicine, East Tennessee State University
Associate Director of Primary Care Research, East Tennessee State University
Director, Tennessee Intervention for Pregnant Smokers
[email protected]
Funding for the studies detailed in this presentation was provided
by the Tennessee Governor’s Office of Children’s Care Coordination
in a grant to Dr. Beth Bailey
OVERVIEW
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2
Previous studies linking prenatal
cigarette exposure to child outcomes
Regional rates & birth outcomes
TIPS – pregnancy smoking intervention
program
TIPS participants: Smoking-related
outcomes at birth
TIPS participants: Smoking-related
outcomes at 15 months
WHAT DO WE KNOW?

Smoking during pregnancy has been definitively
indicated as a causal factor in poor birth outcomes

Biggest impact has been seen on birth weight
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decrements of ~250gm any level of smoking
up to ~400gm for heavier smoking
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Lesser, but significant impact on preterm delivery –
up to 10 days early for heavier smoking (indicates
growth restriction mechanism)

Significantly decreased Apgar scores, and increased
rates of NICU admissions are seen for babies born to
smokers
3
WHAT DO WE KNOW?

Smoking during pregnancy has also
been linked to growth and health into
childhood

Multiple studies have shown that effects
of prenatal smoke exposure on growth
continue into childhood, even after
controlling for postnatal smoke exposure

By age 7, children with prenatal smoke
exposure still have not caught up in
stature – an inch or more shorter on
average, with significantly decreased
head circumferences compared to those
without exposure
4
WHAT DO WE KNOW?

Smoking during pregnancy also significantly
increases the risk of many health problems into
childhood and adolescence including:
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5
SIDS
Asthma
Allergies
Respiratory infections
Ear infections
Effects are evident even without, or controlling for,
postnatal smoke exposure
WHAT DO WE KNOW?

Beyond health and growth effects, dozens of studies
have linked prenatal smoke exposure to
developmental problems

Exposure increases the risk for cognitive and
language delays, and behavioral and emotional
problems in childhood and through to adulthood

The magnitude of these effects is as large or larger
than effects seen for other prenatal exposures
including alcohol, marijuana, illicit drug use, and
abuse of prescription drugs; and due to the relative
prevalence of cigarette smoking, these effects are
much more common
6
WHAT DO WE KNOW?

Several studies have noted a decrease in overall IQ of
nearly 10 points due to prenatal smoke exposure
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Language delays of a year or more have been noted
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Rates of attention problems, including a 50%
increased rate of ADHD diagnosis have been reported
in many studies
7
WHAT DO WE KNOW?
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8
Children with prenatal cigarette exposure have
elevated levels of depression and anxiety disorders
Substantially increased rates of conduct problems,
including ODD and encounters with juvenile
authorities
Greatly increased risk for later smoking and
substance use, as well as increased likelihood of
addiction
WHAT DO WE KNOW?

The mechanisms by which smoking during
pregnancy may impact child development have
not been fully elucidated

We do know that decreased oxygen from the
smoke itself plays a role; the nicotine and other
chemicals in cigarettes also have been shown to
impact the development of neurotransmitters and
receptor sites

We also know that the amount of cigarette
exposure and the timing of the exposure are
important
9
WHAT DO WE KNOW?

Many studies have found a dose response
between prenatal smoke exposure and outcomes
– especially between 2 and 10 cig/day

More cigarettes per day= worse outcomes

No real threshold – have seen effects with as few
as 2 cigarettes per day; issue of underreporting
means this may not be entirely accurate though

However, greatest effects seen
at a half a pack/day or more
10
WHAT DO WE KNOW?

There is not yet a definitive answer on how the timing
of pregnancy smoking impacts outcomes

For most exposures, early pregnancy exposure is
more harmful than later exposure
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For cigarette exposure, this does not appear to be the
case for all outcomes
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Effects on growth and health appear to occur mostly
with late pregnancy exposure; small scale studies and
animals models

However, some evidence suggests that early exposure
may have more subtle effects; but reports are mixed
11
WHAT DO WE KNOW?

What we know about the effects of
prenatal smoke exposure, as well
as dose and timing are important
for intervention efforts

Suggests that quitting smoking by
20-27 weeks may lead to
significant health benefits

Also suggests that even cutting
down on the number of
cigarettes/day can be beneficial
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Further research is needed
12
PRELIMINARY WORK
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Nationally, 12% of pregnant women smoke
In Tennessee, rate is 17%
Suspected the rate in NE TN was much higher, but in
2007 no published data; small scale practice-based
studies suggested 25% or more
Undertook a delivery chart review at local hospitals to
find out regional rates
PRELIMINARY WORK
Local Pregnancy Smoking Rates by Delivery Hospital and Year
Hospital
14
2006
2007
Change
JCMC
31.4% 33.0%
↑1.6%
JCSH
14.5% 17.1%
↑2.6%
Indian Path
29.7% 37.5%
↑7.8%
Sycamore Shoals
42.5% 37.6%
↓4.9%
PRELIMINARY WORK
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15
Is smoking a significant predictor of child outcomes
in the region?
Looked all women who gave birth to live-born
singletons at JCMC & JCSH in 2006 & 2007
Sample contained 4144 women and their newborns,
representative of regional demographics (largely
Caucasian, and disadvantaged (50% plus on
Medicaid))
Data were extracted from electronic delivery logs at
each facility
PRELIMINARY WORK
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25% of the women self-reported as smokers at delivery
The rates of low birth weight and preterm deliveries were
much higher than national averages
Birth Outcome
Non-Smokers
Smokers
Birth Weight (gm)
3299
2965
LBW (%)
8.6%
18.4%
Birth Length (in)
19.8
19.2
Gestational Age (wks)
38.4
37.7
11.1%
18.8%
7.5%
14.6%
PTB (%)
NICU Admission (%)
All differences significant at p<.05 after control for background factors
16
Bailey BA, Jones Cole LK. Rurality and birth outcomes: Findings from Southern Appalachia and the
potential role of pregnancy smoking. Journal of Rural Health, 25(2), 141-149, 2009.
THE INTERVENTION

In January of 2007, the Tennessee
Governor’s office strengthened efforts to
improve birth outcomes in the region and
funded the Tennessee Intervention for
Pregnant Smokers (TIPS) program for
four years; recently refunded through
June 2012

TIPS is a multi-faceted approach that
aims to reduce pregnancy smoking rates
and improve birth outcomes in the 6
counties of NE TN
www.etsu.edu/tips
17
THE INTERVENTION
The program involves:
1) Physician training in providing smoking cessation counseling as a routine
part of prenatal care
2) Nurse training in providing smoking cessation counseling as part of
inpatient & outpatient services
3) Provision of prenatal counseling and case management services
4) Provision of a hospital-based counselor/case manager for admitted highrisk women and those post-partum
5) Education and training programs for nursing , public health, respiratory
therapy, and medical students
6) Community-based education and cessation workshops
7) Development of self-help materials
6 FT staff, 2 PT staff; 2 FTE+ in students each term
18
THE INTERVENTION
All TIPS services are available to prenatal patients in NE TN who:
Are Current smokers
Are Exposed to significant secondhand smoke
Are Former smokers ≤ 2 years smoke-free
Trained prenatal care providers offer:
Brief smoking cessation advice and assistance (5 A’s)
Referrals to TIPS Case Managers
Case Managers provide:
Smoking cessation counseling & support
TIPS self-help materials
Support for the reduction of life stressors
including domestic violence
Referrals to other needed services
19
THE INTERVENTION
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Substantial research component – to evaluate project AND to permit
long term study of effects of prenatal smoke exposure
Phase I (1st 3.5 years)
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In depth interviews in 1st and 3rd trimesters: detailed demographics
and smoking history, alcohol and substance abuse, depression, IPV,
social support, stress, self-esteem, smoking effects knowledge, ADD
screen, temperament, religiosity; biochem verification
Briefer interviews at 6 wks and 6 mo post-partum; medical chart
reviews
Phase I (Years 3.5 on)
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Briefer interviews 4 times during pregnancy; 6 wk, 6 mo PP; medical
chart reviews
All singleton children eligible for developmental assessment at 15
months: health and environment, cognitive, language, behavioral,
motor, assessments; maternal assessment of verbal IQ and
20 psychosocial factors including parenting
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THE INTERVENTION
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Phase I (1st 3.5 years)
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Phase II
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Over 1200 women received case manager
services; 5000+ received care from trained
providers
405 TIPS-eligible women (plus 176 nonsmoker controls) participated in the research
Of the 581 research participants, maintained
over 400 to 6 mo PP
To date nearly 800 received case manager
services
232 have participated in the research
Developmental assessment: 150+ tested
to date; finding about 65%, of those over
90% are participating
INTERVENTION SUCCESS
Quit Completely
12%
6%
28%
Reduction in Smoking by <
half pack/day
Reduction in Smoking by
half pack to pack/day
23%
15%
16%
N=1088; 88% participation rate
22
1+ Quit Attempts But Still
Smoking at Delivery
Reduction in Smoking by
pack/day or more
No Change in Smoking
Amount and No Quit
Attempts
A recent meta-analysis of pregnancy smoking cessation interventions revealed a 15.1% quit rate by delivery for interventions
comparable to or more intense than the TIPS equivalent of 4 or more Case Manager sessions (Lumley et al., 2008).
INTERVENTION SUCCESS
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23
In 3 years, pregnancy smoking rates by delivery
dropped 18% across all practices with case
management services, 10% in practices with trained
providers and no case management
Working with a case manager over multiple sessions
proved particularly effective for smoking cessation,
quit attempts, and reduction, as did provision of
stress management assistance, mental health
referrals, and family smoking
cessation efforts
INTERVENTION SUCCESS
REGIONAL CHANGES IN PREGNANCY SMOKING RATES AND BIRTH OUTCOMES:
35
30.9%
31.2%
30
26.9%
25.8%
24.9%
Percentage
25
Pregnancy Smoking
Preterm Births
20
15
Low Birth Weight Births
13.4%
9.8%
10
11.2%
9.6%
11.2%
10.6%
9.2%
10.1%
8.1%
7.9%
5
0
2006
2007
2008
2009
2010
* Since the beginning of the TIPS project in mid-2007, pregnancy smoking rates in the region have decreased
20.2%, compared to a statewide decrease of only 2.1% during that time.
24 * Also during that time, preterm birth rates have dropped 24.6%, and low birth weight rates have dropped
19.4%. Statewide, rates on low birth weight births have only dropped only 4.2%.
INTERVENTION SUCCESS
Birth Outcomes by Quit Status
Birth Variables
Quit Smoking
(n=307)
Kept Smoking
(n=801)
p
Low birth weight (%)
11.0%
17.3%
.009
Preterm birth (%)
14.5%
16.0%
.075
25
BIRTH OUTCOMES
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26
What is the impact of pregnancy smoking relative to the use of
other substances?
Intervention resources have necessarily been devoted to
helping substance using pregnant women become drug free
Unfortunately, the vast majority of pregnant women who
successfully quit using illicit drugs continue to smoke
Health providers often fail to adequately address smoking
during pregnancy with these women, citing the belief that illicit
drug use is much more harmful to the fetus than smoke
exposure, and the need to save limited time available to focus
on that drug use and other negative health behaviors
BIRTH OUTCOMES
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27
Due to the magnitude of effects of
prenatal cigarette exposure and
the relative prevalence, a recent
population-based study found that
the elimination of smoking would
have a much greater impact on
decreasing poor birth outcomes
than elimination of any other
substance
However, few studies have
quantified the relative impact on
birth outcomes of different
prenatal exposures
Such information in the regional
population is essential
BIRTH OUTCOMES
Looked at the data from research participants who
had delivered
 Not wanting to rely on self-report for illicit drug use
(may be substantial under-reporting), restricted the
sample to infants who had biological testing for
substances at delivery (meconium) [oversampled
substance users]
 Final sample contained 265 infants:
 No cigarette/no drug use (n=46)
 Cigarette use only (n=75)
 Illicit drug use only (n=21)
 Cigarette & illicit drug use (n=123)
 Drugs examined included amphetamines,
barbiturates, benzodiazapines, cannabinoids,
cocaine, and opioids
28

BIRTH OUTCOMES
Substance Use Group Differences on Primary Birth Outcomes
Birth Weight
(gm)
Gestational
Age (wk)
No Cig/No Drug
3232
38.9
Cigarette Only
3068
38.7
Illicit Drug Only
3054
38.1
Cig AND Drug
2954
38.5
F, p
3.70, p=.012 .89, p=.447
Effect for birth weight controlled for significant confounders (education,
29 preeclampsia, race): F=4.55, p=.004
BIRTH OUTCOMES
Effect of Illicit Drug Use on Birth Weight
Adjusted Birth Weights for the 198 Smokers:
 Smoked Only (n=75)
3065 gm
 Smoked AND Used Marijuana (n=39)
3068 gm
 Smoked AND Hard Illicit Drug Use (n=84) 2902 gm
 Test for group difference: F=3.39, p=.036
 Adjusted Birth Weight Difference = 163 gm
 Interpretation: Compared with those who both smoked
and used hard illicit drugs, those who smoked but DID
NOT USE HARD ILLICIT DRUGS had a 163gm gain in
adjusted birth weight – a 5.6% difference.
30
BIRTH OUTCOMES
Effect of Smoking on Birth Weight
Adjusted Birth Weights for the 105 Hard Illicit Drug Users:
31

Hard Drug Use Only (n=21)
3207 gm
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Hard Drug Use AND Smoked (n=84)
2890 gm
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Test for group difference: F=6.28, p=.014
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Adjusted Birth Weight Difference = 317gm
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Interpretation: Compared with those who both smoked
and used hard illicit drugs, those who used hard illicit
drugs BUT DID NOT SMOKE had a 317 gm gain in
adjusted birth weight – an 11.0% difference.
BIRTH OUTCOMES
Effect of BOTH Smoking AND Hard lllicit Drug Use on Birth Weight
Adjusted Birth Weights:
32

No smoking/No Drug Use (n=46)
3248 gm

Smoked AND Hard Drug Use (n=84)
2896 gm
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Test for group difference: F=17.42, p<.001
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Adjusted Birth Weight Difference = 352gm
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Interpretation: Compared with those who both smoked
and used hard illicit drugs, those who USED NEITHER
SUBSTANCE had a 352 gm gain in adjusted birth weight
– a 12.2% difference.
BIRTH OUTCOMES
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Pregnancy substance use was
NOT associated with early
delivery in the current sample
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Pregnancy marijuana use did
not adversely impact birth
weight BEYOND the effects of
cigarette smoking
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This finding suggests that for
pregnant women who both
smoke and use marijuana,
quitting marijuana use while
continuing to smoke will not
lead to improved birth
outcomes
33
BIRTH OUTCOMES
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Pregnancy smoking had twice the impact
on birth weight as illicit drug use
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Findings support the assertions of those
who have suggested that pregnancy
smoking may be at least as detrimental
to the developing fetus as the use of
many illicit drugs
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Findings also support the need to direct
more attention toward increasing
pregnancy smoking cessation efforts
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Pregnant women should be strongly
advised of the risks of continued
smoking, and should be assisted in their
BA, McCook, JG, Hodge A, McGrady L. Infant birth
efforts to eliminate the use of ALL Bailey
outcomes among substance using women: Why quitting smoking
during pregnancy is just as important as quitting harder drugs.
substances, including tobacco
Maternal and Child Health Journal. Published Online First 21
34
Mar 2011; print version in press.
DEVELOPMENTAL TESTING

Project participants are invited to participate in our developmental
follow-up study when the children are 15 months of age

Assessment takes about 2.5 hours, in addition to the
questionnaires the mothers are asked to complete prior to the
appointment
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Child lab assessments include:
 Battelle
 REEL-3
 Test of Sensory Function
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Maternal report of child development:
 Infant Toddler Sensory Profile
 CSBS DP Infant-Toddler Checklist
 Toddler Behavior Assessment Questionnaire
35
DEVELOPMENTAL TESTING

Approximately 65% of eligible participants
have been located at 15 months; over 90%
have participated
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To date, have tested over 150 children
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Data from first 142 on select outcomes
presented here (85 smoking at conception)
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Findings preliminary until all 200+ are tested
and data finalized
36
BACKGROUND DIFFERENCES
Background Factor
Quit Smoking
(n=35)
Kept Smoking
(n=50)
p
Maternal age
23.1
23.8
NS
Maternal education
12.6
11.8
.019
Maternal marital status (% married)
40%
28%
.089
1.8
1.9
NS
Prenatal alcohol exposure
26%
22%
NS
Prenatal marijuana exposure
26%
44%
.067
Prenatal hard illicit drug exposure
10%
12%
NS
Postnatal smoke exposure
23%
52%
.006
Maternal IQ
96.3
94.5
NS
Parity
37
GROWTH & HEALTH DIFFERENCES
Birth Variables
Quit Smoking
(n=35)
Kept Smoking
(n=50)
p
Birth weight (gm)
3334
3071
.045
Low birth weight (%)
5.7%
12.2%
.096
Preterm birth (%)
5.7%
10.2%
NS
NICU admission (%)
6.1%
11.4%
NS
Note: Means and percentages adjusted for maternal education and
marital status, and for prenatal marijuana exposure
38
GROWTH & HEALTH DIFFERENCES
15 Month Variables
Quit Smoking
(n=35)
Kept Smoking
(n=50)
p
Weight (lb)
23.9
22.1
.076
Height (in)
30.6
28.9
.049
Hospitalization (% 1x+ since birth)
12.0%
25.7%
.009
Sick child visits (% 4x+ since birth)
20.0%
37.1%
.040
Respiratory infection (% 1+)
24.0%
48.6%
.017
Ear infection (% 1+)
51.4%
54.0%
NS
Diagnosed with allergies (%)
12.0%
22.9%
.091
Diagnosed with asthma (%)
11.4%
16.0%
NS
Note: Means and percentages adjusted for maternal education and
marital status, and for prenatal marijuana exposure, and postnatal
39 smoke exposure
DEVELOPMENTAL OUTCOME DIFFERENCES
15 Month Outcomes
Quit Smoking
(n=35)
Kept Smoking
(n=50)
p
Gross Motor (%ile)
53.1
47.1
NS
Fine Motor (%ile)
63.0
55.3
.086
Receptive Language (%ile)
56.4
50.5
.079
Expressive Language (%ile)
51.4
44.8
.054
Full Scale IQ
103.8
94.0
.032
Attention and Memory (%ile)
54.7
42.1
.025
Social-Adult Interaction (%ile)
78.3
71.9
.070
Social-Communication (%ile)*
48.2
34.9
.034
Note: Means and percentages adjusted for maternal education and marital status, and for
prenatal marijuana exposure, and postnatal smoke exposure
* - All assessments were laboratory assessments with the exception of Social-Communication
40 which was from the parent-report CSBS
CONCLUSIONS
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Smoking during pregnancy is highly prevalent in NE
TN and contributes to poor birth outcomes

Pregnancy smoking interventions can be highly
effective at reducing smoking rates and improving
outcomes

Quitting smoking by the third trimester can lead to an
improvement in birth outcomes, and better
developmental outcomes at 15 months

Even if a women smokes early in pregnancy, quitting
by the third trimester can significantly reduce the risk
for poor outcomes and should be encouraged
41
ACKNOWLEDGEMENTS

Jessica Scott, MA – Infant Tester

Erin Chambers, MBA – Developmental Study
Coordinator

Lana McGrady, MS – TIPS project Study Manager

All of the TIPS participants and their children

Reference list is available on request
42
PREGNANCY SMOKING AND CHILD
OUTCOMES FROM BIRTH TO 15 MONTHS:
FINDINGS FROM NORTHEAST TENNESSEE
Beth Bailey, PhD
Associate Professor of Family Medicine, East Tennessee State University
Associate Director of Primary Care Research, East Tennessee State University
Director, Tennessee Intervention for Pregnant Smokers
[email protected]
Funding for the studies detailed in this presentation was provided
by the Tennessee Governor’s Office of Children’s Care Coordination
in a grant to Dr. Beth Bailey